1-1     By:  Averitt (Senate Sponsor - Sibley)                H.B. No. 2061
 1-2           (In the Senate - Received from the House April 23, 1999;
 1-3     April 26, 1999, read first time and referred to Committee on
 1-4     Economic Development; May 5, 1999, reported adversely, with
 1-5     favorable Committee Substitute by the following vote:  Yeas 5, Nays
 1-6     0; May 5, 1999, sent to printer.)
 1-7     COMMITTEE SUBSTITUTE FOR H.B. No. 2061                  By:  Sibley
 1-8                            A BILL TO BE ENTITLED
 1-9                                   AN ACT
1-10     relating to coverage by a health benefit plan of certain
1-11     prescription drugs.
1-12           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13           SECTION 1.  Subchapter E, Chapter 21, Insurance Code, is
1-14     amended by adding Article 21.53M to read as follows:
1-15           Art. 21.53M.  COVERAGE FOR OFF-LABEL DRUG USE
1-16           Sec. 1.  DEFINITIONS.  In this article:
1-17                 (1)  "Contraindication" means the potential for, or the
1-18     occurrence of, an undesirable alteration of the therapeutic effect
1-19     of a prescribed drug prescription because of the presence, in the
1-20     patient for whom it is prescribed, of a disease condition, or the
1-21     potential for, or the occurrence of, a clinically significant
1-22     adverse effect of the drug on the patient's disease condition.
1-23                 (2)  "Drug" has the meaning assigned by Section 5,
1-24     Texas Pharmacy Act (Article 4542a-1, Vernon's Texas Civil
1-25     Statutes).
1-26                 (3)  "Health benefit plan" means a plan described by
1-27     Section 2 of this article.
1-28                 (4)  "Indication" means any symptom, cause, or
1-29     occurrence in a disease that points out the cause, diagnosis,
1-30     course of treatment, or prognosis of the disease.
1-31                 (5)  "Peer-reviewed medical literature" means published
1-32     scientific studies in any peer-reviewed national professional
1-33     journal.
1-34           Sec. 2.  SCOPE OF ARTICLE.  (a)  This article applies only to
1-35     a health benefit plan that provides benefits for medical or
1-36     surgical expenses incurred as a result of a health condition,
1-37     accident, or sickness, including an individual, group, blanket, or
1-38     franchise insurance policy or insurance agreement, a group hospital
1-39     service contract, or an individual or group evidence of coverage or
1-40     similar coverage document that is offered by:
1-41                 (1)  an insurance company;
1-42                 (2)  a group hospital service corporation operating
1-43     under Chapter 20 of this code;
1-44                 (3)  a fraternal benefit society operating under
1-45     Chapter 10 of this code;
1-46                 (4)  a stipulated premium insurance company operating
1-47     under Chapter 22 of this code;
1-48                 (5)  a reciprocal exchange operating under Chapter 19
1-49     of this code;
1-50                 (6)  a health maintenance organization operating under
1-51     the Texas Health Maintenance Organization Act (Chapter 20A,
1-52     Vernon's Texas Insurance Code);
1-53                 (7)  a multiple employer welfare arrangement that holds
1-54     a certificate of authority under Article 3.95-2 of this code; or
1-55                 (8)  an approved nonprofit health corporation that
1-56     holds a certificate of authority issued by the commissioner under
1-57     Article 21.52F of this code.
1-58           (b)  This article does not apply to:
1-59                 (1)  a plan that provides coverage:
1-60                       (A)  only for a specified disease or other
1-61     limited benefit;
1-62                       (B)  only for accidental death or dismemberment;
1-63                       (C)  for wages or payments in lieu of wages for a
1-64     period during which an employee is absent from work because of
 2-1     sickness or injury;
 2-2                       (D)  as a supplement to liability insurance;
 2-3                       (E)  for credit insurance;
 2-4                       (F)  only for dental or vision care;
 2-5                       (G)  only for hospital expenses; or
 2-6                       (H)  only for indemnity for hospital confinement;
 2-7                 (2)  a small employer health benefit plan written under
 2-8     Chapter 26 of this code;
 2-9                 (3)  a Medicare supplemental policy as defined by
2-10     Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
2-11     as amended;
2-12                 (4)  workers' compensation insurance coverage;
2-13                 (5)  medical payment insurance coverage issued as part
2-14     of a motor vehicle insurance policy; or
2-15                 (6)  a long-term care policy, including a nursing home
2-16     fixed indemnity policy, unless the commissioner determines that the
2-17     policy provides benefit coverage so comprehensive that the policy
2-18     is a health benefit plan as described by Subsection (a) of this
2-19     section.
2-20           Sec. 3.  MINIMUM STANDARDS OF COVERAGE.  (a)  A health
2-21     benefit plan that provides coverage for drugs must provide coverage
2-22     for any drug prescribed to treat an enrollee for a covered chronic,
2-23     disabling, or life-threatening illness if the drug:
2-24                 (1)  has been approved by the Food and Drug
2-25     Administration for at least one indication; and
2-26                 (2)  is recognized for treatment of the indication for
2-27     which the drug is prescribed in:
2-28                       (A)  a prescription drug reference compendium
2-29     approved by the commissioner for the purpose of this article; or
2-30                       (B)  substantially accepted peer-reviewed medical
2-31     literature.
2-32           (b)  Coverage of a drug required by this section shall
2-33     include coverage of medically necessary services associated with
2-34     the administration of the drug.
2-35           (c)  A drug use that is covered under this section may not be
2-36     denied based on a "medical necessity" requirement except for
2-37     reasons that are unrelated to the legal status of the drug use.
2-38           (d)  This section does not require coverage for:
2-39                 (1)  experimental drugs not otherwise approved for any
2-40     indication by the Food and Drug Administration; or
2-41                 (2)  any disease or condition that is excluded from
2-42     coverage under the plan.
2-43           (e)  A health benefit plan is not required to cover a drug
2-44     the Food and Drug Administration has determined to be
2-45     contraindicated for treatment of the current indication.
2-46           Sec. 4.  RULES.  The commissioner may adopt rules to
2-47     implement this article.
2-48           SECTION 2.  This Act takes effect September 1, 1999,and
2-49     applies only to a health benefit plan that is delivered, issued for
2-50     delivery, or renewed on or after January 1, 2000.  A health benefit
2-51     plan that is delivered, issued for delivery, or renewed before
2-52     January 1, 2000, is governed by the law as it existed immediately
2-53     before the effective date of this Act, and that law is continued in
2-54     effect for that purpose.
2-55           SECTION 3.  The importance of this legislation and the
2-56     crowded condition of the calendars in both houses create an
2-57     emergency and an imperative public necessity that the
2-58     constitutional rule requiring bills to be read on three several
2-59     days in each house be suspended, and this rule is hereby suspended.
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